Monday, June 13, 2016

Guidelines Updated for Optimal Perioperative Geriatric Care

Extensive updates to best-practice recommendations for the
perioperative care of patients 65 years of age and older have just been
released; anesthesiologists take note.

“Optimal Perioperative Management of the Geriatric Patient: A Best
Practices Guideline,” provides a management checklist for
anesthesiologists and other medical professionals when caring for older
patients facing surgery.

The guidelines cover the use of anesthesia and perioperative
analgesia in older patients. Best practices for dealing with
perioperative nausea and vomiting, preventing postoperative
complications including hypothermia and fluid management are also
detailed.

The guidelines were developed by the ACS National Surgical Quality
Improvement Program and the Geriatrics-for-Specialists Initiative of the
American Geriatrics Society (AGS). The John A. Hartford Foundation
provided financial support.

Mark D. Neuman, MD, assistant professor of anesthesiology and
critical care and assistant professor of medicine (geriatrics) at the
Perelman School of Medicine, University of Pennsylvania, in
Philadelphia, helped write the new guidelines.

He said the ultimate aim is to help anesthesiologists and other medical practitioners “deliver great care for older adults.”

Clinical Implications
“I think that individual practitioners may take a look at these
guidelines and take input from them on how they may improve their
individual practices,” said Dr. Neuman, who also is chair of the
American Society of Anesthesiologists’ Committee on Geriatric
Anesthesia.

Anesthesiologists need to consider some of the physiologic changes
common to older patients when drawing up an anesthetic plan, according
to the recommendations.

Physiologic alterations in the cardiovascular, pulmonary, nervous,
endocrine and hepatic systems of older adults can have significant
clinical implications for the use of anesthesia. Decreased venous
compliance, for example, can lead to susceptibility to hypotension,
while a drop in neurotransmitters can lead to an increased risk for
cognitive dysfunction and postoperative delirium, for instance.
However, there is not enough evidence for a single, recommended
approach when drawing up an anesthesia plan for older patients, with
anesthesiologists urged to use their best clinical judgment, the
guidelines noted.

Regional anesthesia can be a beneficial alternative to general
anesthesia in some surgical procedures in older adults, leading to
reduced postoperative confusion.

The use of regional anesthesia may be considered as an alternative to
general anesthesia in appropriate patients for hip fracture repair,
with benefits including a lower chance of 30-day mortality and reduced
need for sedatives, the guidelines noted.

Elective hip and knee arthroplasty and lower limb revascularization
are surgical procedures in which regional anesthesia may be an
appropriate alternative.

Regional anesthesia can lead to reduced mortality in patients
undergoing elective hip and knee operations, while also resulting in
better pain scores, a lessened risk for infection, and reduced need for
sedation and critical care.

For lower limb revascularization, the main benefit of regional anesthesia is a lowered risk for pneumonia.

Still, there is insufficient evidence for a blanket recommendation
that regional anesthesia be considered the dominant approach for older
adults and other groups of patients, the guidelines cautioned.

Anesthesiologists also are called upon to take a multimodal approach
to treating pain in older adults, emphasizing alternatives to the use of
opioids.

Anesthesiologists should be sparing in their use of opioid-based
medications in older adults, who can experience problems including
cognitive dysfunction or delirium, with a higher risk for hemodynamic
and respiratory issues, according to the guidelines.

When treating older adults, anesthesiologists are urged to develop an
analgesic plan before surgery that considers altered physiology and
increased sensitivity. The patient’s pain history and a physical exam
should be noted.

Nerve Blocks and Epidurals
Some regional techniques for analgesia also may be appropriate in
older patients as an alternative to opioid-based pain medications.

Combined with general anesthesia, the use of nerve blocks and
epidurals can have multiple benefits, reducing pain, sedation and
tracheal intubation/mechanical ventilation time while cutting the risk
for perioperative myocardial infarction and perioperative cardiovascular
complications. Gastrointestinal function returns faster.

In particular, major abdominal surgery, hip fracture repair,
thoracotomy, and elective hip and knee arthroplasty are procedures for
which epidurals with regional anesthesia or nerve blocks are viable
options.

Pre- or postoperative nerve blocks are particularly effective during
hip fracture repair, and should be for “all patients” undergoing the
procedure.

Thoracic epidural anesthesia also should be considered for “appropriate” thoracotomy patients.
Local anesthetic delivered with an epidural may be considered for
major abdominal surgery, including the repair of an open abdominal
aortic aneurysm.

Paravertebral blocks failed to get an endorsement for use in older
adults. The guidelines state that the “role of paravertebral blocks in
this patient group is not clear,” and note an increased risk for
hypotension.

When dealing with older adults scheduled for surgery,
anesthesiologists are asked to carefully assess risk factors for
postoperative nausea and vomiting (PONV), weighing risk mitigation
strategies for those patients considered to be moderate or high risk.

There are also several PONV drugs on the AGS updated Beers list of
medications that are not recommended for use in older patients.

Special care also is needed to prevent hypothermia in older adults
undergoing surgery and following the administration of IV fluids. The
health care team should monitor core temperature in surgeries lasting
more than a half hour, while forced air warmers and warmed IV fluids
should be used as well, the guidelines recommended.

When administering IV fluids, “the combined effects of aging,
anesthetics, analgesics and anxiolytics on physiology” should be
carefully weighed.

However, there is not enough evidence to support a best-practice recommendation for any particular fluid management strategies.

“More than ever, 80-, 90- and even 100-year-olds are undergoing
surgery,” noted Terry Fulmer, PhD, RN, FAAN, president of the Hartford
Foundation, in a press statement.